History Taking · Intermediate · Psychiatry

Low Mood with Persistent Thoughts

Practise this PLAB 2 history taking station on Suicide Risk Assessment. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the emergency department. Viktor Kozlov, a 34-year-old man, has attended with low mood for the past two weeks. He is referred by his GP with concerns about his wellbeing. Please take a focused psychiatric history, assess suicide risk, and discuss management.

Background notes: PMH: None significant

What this station tests

  • Direct questioning about suicidal ideation, plans, and intent: each question opens the next, do not avoid
  • Asking about suicide does not increase risk: avoiding the topic prevents identification
  • Risk and protective factors: isolation, access to means, alcohol versus daughter, future plans
  • Safety planning: warning signs, coping strategies, contacts, means restriction
  • Crisis team referral for moderate risk: not admission unless requested or high risk

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Suicide risk assessment requires direct, calm questioning about suicidal thoughts, plans, and intent. Avoiding the topic does not protect the patient: it prevents identification of risk. Viktor is 34, divorced, in ED with 2 weeks of low mood. His GP referred him with concern about safety. Open with: 'Viktor, thank you for coming. Your GP was worried about you. Can you tell me how you have been feeling?'

Core approach

Systematic risk assessment. Start with mood: 'How has your mood been?' Then escalate: 'Have you felt that life is not worth living?' 'Have you had thoughts of ending your life?' 'Have you thought about how you might do it?' 'Have you made any plans or preparations?' 'What has stopped you so far?' Each question opens the next. Do not avoid asking directly about suicide: it does not increase risk.

Assess the risk factors. Recent divorce (2 years ago). Lives alone. Social isolation. High-pressure job. Access to means. Male (higher completion rate). Alcohol use (increases impulsivity). Any previous attempts? Family history of suicide? Recent losses?

Protective factors. His daughter (he sees her alternate weekends). His colleague who noticed. Any religious or moral objections to suicide. Future plans or commitments. These factors reduce risk and must be identified.

He has thoughts of taking an overdose but has not obtained tablets. He has not written a note. His daughter is his main reason for staying alive. This is moderate risk: active ideation with method but no specific plan, preparation, or intent to act imminently.

Closing and safety netting

Management depends on risk level. Moderate risk: crisis team referral for home treatment, not admission unless he requests it. Safety plan: identify warning signs, coping strategies, people to contact, professional contacts (crisis team number, Samaritans 116 123). Reduce access to means: 'Is there anyone who could hold your medications for you?'

Do not discharge alone. Ensure he has a named contact on the crisis team. Arrange follow-up within 24 to 48 hours. 'Viktor, I am glad you came in today. You are not alone in this, and there is help available.' Safety net: crisis team contact, 999 if he feels unable to keep himself safe. Do not make promises about confidentiality that you cannot keep (if risk is imminent, information sharing may be necessary).

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for suicide risk assessment. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: Systematic escalation of suicidal questioning. Risk factors identified. Protective factors identified. Means and access assessed. Previous attempts asked. Alcohol use assessed.

Costs marks: Avoiding direct questioning. Not assessing means. Not identifying protective factors.

Domain 2 (Primary focus)

Scores well: Risk level determined (moderate). Crisis team referral. Safety plan created. Means restriction discussed. Follow-up within 48 hours. Not discharging alone.

Costs marks: No risk stratification. No safety plan. No crisis referral. Discharging alone.

Domain 3 (Primary focus)

Scores well: Calm, direct, non-judgmental questioning. Creating a safe space for disclosure. Acknowledging his courage in coming. Genuine warmth without false reassurance.

Costs marks: Awkward or avoidant. Minimising his distress. False reassurance ('everything will be fine'). Cold or clinical.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Avoiding direct questions about suicide: indirect questioning ('are you thinking of doing anything silly?') minimises the seriousness and prevents accurate risk assessment
  2. Not asking about means and access: knowing he has thought about overdose but has not obtained tablets is critical risk stratification
  3. Not identifying protective factors: his daughter is his main reason for staying alive, and this should be explicitly acknowledged

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

What is the best way to take a suicide risk assessment history in PLAB 2?

Suicide risk assessment requires direct, calm questioning about suicidal thoughts, plans, and intent. Avoiding the topic does not protect the patient: it prevents identification of risk. Viktor is 34, divorced, in ED with 2 weeks of low mood.

Where are marks won and lost in this suicide risk assessment station?

Examiners reward: Systematic escalation of suicidal questioning. Risk factors identified. Protective factors identified. Means and access assessed. Previous attempts asked. Candidates are penalised for: Avoiding direct questioning. Not assessing means. Not identifying protective factors.

Where do candidates most often go wrong in this station?

Avoiding direct questions about suicide: indirect questioning ('are you thinking of doing anything silly?') minimises the seriousness and prevents accurate risk assessment.

Can I do well in this station without real-world experience of suicide risk assessment?

This station rewards process over personal experience. The skill being assessed: Asking about suicide does not increase risk: avoiding the topic prevents identification. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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